Alzheimer's & Ms & Parkinsons 2

Front 1

TOUCH Prescribing Program associated with Natalizumab (Tysabri)

Back 1

1. prescribers and patients enrolled can prescribe and receive
2. certain pharmacies and infusion sites authorized can dispense and infuse
3. must re-authorize treatment every 6 months

Front 2

Mechanism of Action of Mitoxantrone (Novantrone)

Back 2

*IMMUNOSUPPRESSANT*
1. inhibits the proliferation of T-cells, B-cells, and macrophages; impairs the secretion of molecules that promote inflammation

Front 3

Clinical Use of Mitoxantrone (Novantrone)

Back 3

rapidly advancing MS disease who have failed other therapies

Front 4

Major Contraindication for Mitoxantrone (Novantrone)

Back 4

Cardiac Toxicity which can lead to CHF - must limit the amount per lifetime

Front 5

Patient Education for Mitoxantrone (Novantrone)

Back 5

1. Monitor for heart failure symptoms
2. monitor for symptoms of myelosuppression
3. blue-green urine color and bluish discoloration of sclera

Front 6

Monitoring for Mitoxantrone (Novantrone)

Back 6

1. Weight
2. LVEF (left ventricular ejection fraction)
3. CBC
4. LFTs
5. pregnancy test

Front 7

Mechanism of Action of Fingolimod (Gilenya)

Back 7

reduction of lymphocyte migration into the CNS

Front 8

Clinical use of Fingolimod (Gilenya)

Back 8

relapsing forms of MS; use as first or second-line therapy

Front 9

Pregnancy Category for Fingolimod (Gilenya)

Back 9

C - must use contraception during and for 2 months after stopping treatment

Front 10

Monitoring for Fingolimod (Gilenya)

Back 10

1. Bradycardia - electrocardiogram
2. Infections - CBC
3. Macular Edema - eye exams
4. Respiratory Effects - spirometric evaluation
5. Hepatic Effects - LFTs

Front 11

Positive Lifestyle and Psychosocial for MS

Back 11

1. very low saturated and vit D supplementation
2. minimal, regular sunlight exposure
3. positive mental and social health and coping
4. exercise

Front 12

Risk Factors for Parkinson's

Back 12

1. 1st degree relative
2. rural living
3. drinking well water
4. heavy metal, hydrocarbon, pesticide exposure
5. male

Front 13

Pathophysiology of Parkinson's

Back 13

* Dopamine stores are depleted
* Nigrostiatal pathways destroyed
* Imbalance of ACh, DA, GABA, Serotonin, etc
**Excess of ACh and a deficiency of DA

Front 14

General HallMark Symptoms of Parkinson's

Back 14

1. Rigidity
2. Resting Tremor
3. Bradykinesia

Front 15

Motor Features of Parkinson's

Back 15

1. Decreased dexterity
2. Difficulty speaking(dysarthria) and swallowing(dysphagia)
3. Quiet speaking(hypophonia), hypomimia(few facial expressions), micrographia(small writing)
4. Festinating Gait

Front 16

Autonomic Features of Parkinson's

Back 16

1. bladder disorder
2. constipation
3. fatigue
4. Skin problem(seborrhea)
5. Excessive salivating/drooling(sialorrhea)
6. orthostatic hypotension

Front 17

Psychiatric Features of Parkinson's

Back 17

1. anxiety
2. apathy
3. confusion
4. insomnia
5. depression

Front 18

Diagnosis of Parkinson's

Back 18

1. 2 of 3 hallmark features
2. response to pharmacotherapy

Front 19

Initial Signs and Symptoms of Parkinson's

Back 19

*Insidious onset
*usually sensory symptoms and tremor
*little impairment of activities
*no pharmacotherapy required

Front 20

Advanced Signs and Symptoms of Parkinson's

Back 20

*greater impairment of daily activities, quality of life
*psychiatric changes requiring additional pharmacotherapy
*hypomobility akinesia

Front 21

Goals of Treatment of Parkinson's

Back 21

1. Improve motor and non-motor function
2. maintain quality of life
3. avoid drug-induced complications

Front 22

Non-Pharmacological Treatments of Parkinson's

Back 22

1. Exercise
2. Nutrition
3. Education
4. Support Groups
5. Neurosurgery

Front 23

Anticholinergics used to treat Parkinson's

Back 23

1. Benztropine (Cogentin)
2. Trihexyphenidyl (Artane)

Front 24

MAO-B Inhibitors used to treat Parkinson's

Back 24

1. Selegiline (Eldepryl, Zelapar)
2. Rasagiline (Azilect)

Front 25

COMT Inhibitors used to treat Parkinson's

Back 25

1. Entacapone (Comtan)
2. Tolcapone (Tasmar)

Front 26

Dopamine Agonists used to treat Parkinson's

Back 26

1. Bromocriptine (Parlodel)
2. Ropinirole (Requip)
3. Pramipexole (Mirapex)
4. Apomorphine (Apokyn)

Front 27

Other Medications used to treat Parkinson's

Back 27

1. Carbidopa (Lodosyn)
2. Carbidopa/Levodopa (Sinemet, Parcopa)
3. Carbidopa/Levodopa/Entacapone (Stalevo)
4. Amantadine (Symmetrel)

Front 28

Mechanism of Action of Anticholinergics for Parkinson's

Back 28

overcomes the increased cholinergic activity
*balances ACh and DA*

Front 29

Indication for Anticholinergics for Parkinsons

Back 29

alone or as adjunct therapy

Front 30

Clinical Pearls for Anticholinergics

Back 30

1. most useful for tremor
2. sometimes useful for dystonia
3. little benefit for other clinical features
4. avoid use in elderly (over 65 years)

Front 31

Possible MOA for Amantadine

Back 31

increases DA release, inhibits DA reuptake, stimulates DA receptors or inhibits NMDA

Front 32

Indication for use of Amantadine

Back 32

Monotherapy or Symptomatic and adjunct treatment

Front 33

ADRs for Amantadine

Back 33

CV: orthostatic hypotension, peripheral edema
CNS: confusion, hallucinations, insomnia, agitation
GI: constipation, nausea, xerostomia
Derm: livedo reticularis
Dry Nose

Front 34

Clinical Pearls for Amantadine

Back 34

1. useful in early, mild disease
2. benefit for tremor, rigidity, bradykinesia
3. renally dosed

Front 35

MOA of Levodopa

Back 35

direct precursor to dopamine
1. penetrates CNS and is converted to dopamine by CENTRAL L-amino acid decarboxylase
2. can also be converted by PERIPHERAL L-amino acid decarboxylase and cannot enter CNS

Front 36

MOA of Carbidopa

Back 36

L-amino acid decarboxylase inhibitor - allows levodopa to escape conversion in the periphery

Front 37

Indication for Levodopa/Carbidopa

Back 37

Treatment in both early and late stages
*ultimately all patients will be on it

Front 38

ADRs of Levodopa/Carbidopa

Back 38

CV: arrhythmia(more common with levodopa alone), chest pain, orthostatic hypotension
CNS: anxiety, depression, abnormal dreams, hallucinations, confusion
GI: ab pain, diarrhea, constipation, nausea, vomit

Front 39

Max dose of Carbidopa

Back 39

200mg

Front 40

Max dose of Levodopa

Back 40

2000mg

Front 41

Clinical Pearls for Levodopa/Carbidopa

Back 41

1. most effective treatment
2. dyskinesias and other motor complications are common
3. akinesia improves rapidly & tremor/rigidity respond well. Balance/gain may not improve

Front 42

Complications of DA therapy (levodopa/carbidopa)

Back 42

1. Delayed-On or No-On
2. Wearing Off
3. On/Off
4. Dyskinesias
5. Freezing
6. Dystonias
7. Myclonus
8. Akathisia

Front 43

"Delayed-On" or "No-On"

Back 43

Signs: delayed or minimal response to previously effective dose

Treatment: give on empty stomach, chew or crush tab, switch to ODT, increase dose, add DA agonist

Front 44

"Wearing off"

Back 44

Signs: decreased duration of response; occurs at end of dose

Treatment: change to CR prep, increase frequency, add MAOB inhibitor or DA agonist or COMT inhibitor, long acting agents at night

Front 45

"On/Off"

Back 45

Signs: fluctuations from normal/good to poor movement

Treatment: add DA agonist, switch from IR to CR, add MAOB or COMT inhibitor

Front 46

Dyskinesias

Back 46

Signs: abnormal involuntary jerking of face, neck, arms, legs

Treatment: decrease dose, change to CR prep, add amantadine

Front 47

"Freezing"

Back 47

Signs: temporary, sudden, involuntary inability to move (usually lower extremities)

Treatment: increase dose, add DA agonist or MAOB inhibitor, physical therapy

Front 48

Dystonias

Back 48

Signs: sustained muscle contraction in early morning

Treatment: add DA agonist, dose CR at bedtime, baclofen

Front 49

Myoclonus

Back 49

Signs: repetitive jerking movements at night

Treatment: decrease nighttime dose, clonazepam

Front 50

Akathisia

Back 50

Signs: restless feeling

Treatment: add nighttime dopaminergic med

Front 51

MOA of MAO-B inhibitor

Back 51

selectively inhibits MAOa in the brain = inhibits DA degradation = enhanced dopaminergic activity

Front 52

Indication of use for MAO-B inhibitor

Back 52

1. adjunct therapy
2. initial monotherapy in early PD

Front 53

Clinical Pearls with MAO-B Inhibitors

Back 53

1. often used as initial monotherapy with mild symptoms
2. bioavailability is increased with ODT

Front 54

ADRs of MAO-B Inhibitors

Back 54

CNS: mood changes, insomnia, dizziness
GI: nausea, vomiting
Neuromuscular: dyskinesias

Front 55

Warnings with MAO-B inhibitors

Back 55

absolute contraindication with meperidine (Serotonin Syndrome)

Front 56

MOA of COMT inhibitors

Back 56

inhibit peripheral and central conversion of levodopa to dopamine by inhibiting catechol-o-methyltransferase enzyme

Front 57

Indication for use of COMT Inhibitors

Back 57

for combination therapy only, not first line

Front 58

Warnings for COMT inhibitors (tolcapone)

Back 58

fatal hepatotoxicity (reserved for last line)

Front 59

ADRs of COMT inhibitors

Back 59

CV: orthostatic hypotension, syncope
CNS: dizziness, fatigue, hallucination, anxiety
GI: nausea, vomit, diarrhea, constipation
Urinary: brown-orange urine color (COUNSEL)
Neuromuscular: dyskinesias, muscle cramps, stiffness

Front 60

Clinical Pearls for COMT inhibitors

Back 60

1. can allow a lower dose of levodopa
2. delayed onset of diarrhea (weeks to months later)
3. monitor LFTs at baseline then q2-4 week for 6 months

Front 61

MOA of dopamine agonists

Back 61

directly stimulate DA receptors

Front 62

Indication of use for Dopamine agonists

Back 62

initial monotherapy or adjunctive therapy to carbidopa/levodopa

Front 63

ADRs of Dopamine Agonists

Back 63

CV: orthostatic hypotension, edema, chest pain
CNS: somnolence, insomnia, dizziness, hallucinations
GI: nausea, constipation
Neuromuscular: dyskinesia, weakness

Front 64

Dopamine agonist with highest incidence of ADRs

Back 64

bromocriptine

Front 65

Dopamine agonist that can be used as "rescue therapy" by subq injection

Back 65

apomorphine

Front 66

Clinical Pearls of Dopamine agonists

Back 66

1. longer duration of action than levodopa & fewer motor complications
2. non-ergot agents have fewer ADRs
3. apomorphine requires pretreatment with trimethobenzamide(Tigan)

Front 67

Essential Tremor

Back 67

disorder of the nervous system that causes involuntary shaking movements that can affect any part of the body but usually the hands

Front 68

Symptoms of Essential Tremor

Back 68

1. small, rapid movements (5+ times per second)
2. "yes-yes" or "no-no" motion of head
3. shaking or quivering speech

Front 69

Non Pharm Treatment of Essential Tremor

Back 69

1. Relaxation techniques
2. avoid caffeine
3. use alcohol sparingly
4. obtain enough rest

Front 70

2 classes of drugs used for treatment of Essential Tremor

Back 70

1. Beta Blockers (Propranolol, Atenolol, sotalol, nadalol)
2. Primidone (anticonvulsant)

Front 71

Clinical Pearl of Beta Blockers for Essential Tremor

Back 71

1. most commonly used meds

Front 72

Clinical Pearls for Primidone

Back 72

Effective for limb tremor